Ultrasound-guided transrectal extended prostate biopsy： a prospective study

AIM: To evaluate the diagnostic value of the 10 systematic transrectal ultrasound-guided (TRUS) prostate biopsy compared with the sextant biopsy technique for patients with suspected prostate cancer. Methods: One hundred and fifty-two patients with suspected prostate cancer were included in the study. Patients were entered in the study because they presented with high levels of prostate specific antigen (PSA) (over 4 ng/mL) and/or had undergone an abnormal digital rectal examination (DRE). In addition to sextant prostate biopsy cores, four more biopsies were obtained from the lateral peripheral zone with additional cores from each suspicious area revealed by transrectal ultrasound. Sextant, lateral peripheral zone and suspicious area biopsy cores were submitted separately to the pathological department. Results: Cancer detection rates were 27.6% (42/152) and 19.7% (30/152) for the 10-core and sextant core biopsy protocols, respectively. Adding the lateral peripheral zone (PZ) to the sextant prostate biopsy showed a 28.6% (12/42) increase in the cancer detection rate in patients with positive prostate cancer (P < 0.01). The cancer detection rate in patients who presented with elevated PSA was 29.3% (34/116). When serum PSA was 4-10 ng/mL TRUS-guided biopsy detected cancer in 20.6%, while the detection rate was 32.4% and 47.0% when serum PSA was 10-20 ng/mL and above 20 ng/mL, respectively. Conclusion: The 10 systematic TRUS-guided prostate biopsy improves the detection rate of prostate cancer by 28.6% when compared with the sextant biopsy technique alone, without increase in the morbidity. We therefore recommend the 10-core biopsy protocol to be the preferred method for early detection of prostate cancer.     

Clinical, biochemical and pathological features of initial and repeat transrectal ultrasonography prostate biopsy positive patients

BACKGROUND: Using sextant biopsy, 16-41% of prostate cancers were diagnosed on repeat biopsy. The objective of the present study was to compare the differences in the clinical, biochemical and pathological features between patients with positive results on initial and repeat biopsies, with an aim to identify factors that can be used to improve the detection rate of transrectal ultrasound (TRUS) biopsy of the prostate. METHODS: Between February 2000 and April 2001, 222 patients with a mean age of 64 years (range 38-85) underwent TRUS-guided 10-core prostate biopsy for either abnormal prostate specific antigen (PSA) levels (>4 ng/mL) and/or abnormal digital rectal examination (DRE). Of this number, 165 patients underwent their first biopsy, whereas 45 and 12 patients had had one or two previous biopsies, respectively. RESULTS: Prostate cancer detection rates for the initial biopsy group (n = 165), second biopsy group (n = 45) and third biopsy group (n = 12) were 29.7, 23.0 and 41.7%, respectively. Six patients who had a negative first 10-core biopsy underwent a second 10-core biopsy and one patient (16%) was found to have cancer. Apart from total prostate volume, there were no significant statistical differences between the patient age, mean total PSA, PSA density, PSA-transition zone density, DRE and TRUS findings between the initial and repeat biopsy groups of subjects who had cancer. Those who had cancer detected only on repeat biopsies had larger prostate glands (P = 0.041). CONCLUSION: Patients who had cancer detected only on repeat biopsies had bigger prostate glands, supporting the hypothesis that TRUS sextant biopsy as a technique suffers the error of under-sampling in a bigger prostate.     

An extended 10-core transrectal ultrasonography guided prostate biopsy protocol improves the detection of prostate cancer

OBJECTIVE: To evaluate the efficacy of TRUS guided 10-core biopsy strategy for Turkish patients who had biopsy of the prostate for the first time. METHODS: Between February 2001 and May 2003, 303 consecutive men with suspected prostate cancer were included in the study. Indications for TRUS guided prostate biopsy were: abnormal digital rectal examination and/or a serum PSA over 2.5 ng/ml. All of the patients underwent a 10-core biopsy protocol with additional core from the each suspicious area detected by TRUS. Besides the sextant technique, 4 more biopsies were obtained from the lateral peripheral zone. We aimed to analyze whether cancer detection improved with the extended versus the standard sextant biopsy in our series overall and in each subgroup. RESULTS: Of 303 patients 94 (31%) were positive for prostate cancer. Median age and PSA of prostate cancer patients were significantly higher than of the non-cancer patients. Besides prostate volumes of the cancer patients were significantly lower than of the non-cancer ones. The cancer detection rates were 31% (94/303) and 23.1% (70/303) for the 10-core biopsy strategy and sextant biopsy strategies, respectively. Thus the 10-core biopsy technique increased cancer detection rate by 25.5% (24/94) for the whole group of patients. A statistically significant number of additional cancers were detected with 10-core biopsy strategy for all the subgroups of the patients. Furthermore 10-core biopsy protocol detected more cancers (at least 6.4%) than all the probable different combinations of 8-core biopsy protocols. Among the 94 cancer patients, biopsy from a suspicious area revealed cancer in 31.9% of them; however, in all of these patients cancer was already present in the 10-core biopsy. On the other hand, lesion biopsies revealed 5.7% additional cancers if sextant technique was used. There were only 3 (0.9%) serious complications requiring hospitalization and all 3 were infections controlled by appropriate antibiotics. CONCLUSION: Adding 4 lateral peripheral biopsies to the conventional sextant biopsy (10-core biopsy strategy) technique has increased the cancer detection rate by 25.5% without significant morbidity and without increasing the number of insignificant cancers. 10-core biopsy protocol was superior to all probable 8-core biopsy protocols in our study group. Additional biopsies from suspicious areas detected by transrectal ultrasonography revealed no further benefit if 10-core technique was used. We therefore suggest that 10-core biopsy protocol should be the preferred strategy in early detection of prostate cancer.     

Effect of peripheral biopsies in maximising early prostate cancer detection in 8-, 10- or 12-core biopsy regimens

OBJECTIVE: To assess the cancer detection rate per individual core biopsy in a 12-core protocol and develop an optimal biopsy regimen for detecting early prostate cancer. PATIENTS AND METHODS: The study included 445 new patients who had a 12-core transrectal ultrasonography (TRUS)-guided prostatic biopsy over a 40-month period. The 12- core biopsy protocol included parasagittal sextant and six peripheral biopsies. The cancer detection rate per individual core was evaluated to give an optimal biopsy protocol. RESULTS: Prostate cancer was detected in 142 patients (31.9%). Parasagittal sextant biopsy would have failed to detect 40 (28.2%) of the cancers. Among the various possible biopsy protocols, the optimum 10-core biopsy strategy excluding the parasagittal mid-zone biopsies from the 12-core protocol achieved a cancer detection rate of 98.6%. CONCLUSION: The cancer detection rate increased from 71.8% for parasagittal sextant biopsies to 88.7% by adding peripheral basal biopsies (8-biopsy protocol); 98.6% of cancers in the series would have been detected with a 10-biopsy strategy omitting the parasagittal mid-zone biopsies. Thus we recommend a 10-core protocol incorporating six peripheral biopsies in patients with elevated age- specific prostate-specific antigen levels (2.6-10.0 ng/mL) for maximising cancer detection.     

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.     

Significance of routine transition zone biopsies in Japanese men undergoing transrectal ultrasound-guided prostate biopsies

BACKGROUND: The objective of this study was to evaluate the clinical significance of additional routine transition zone (TZ) biopsies in Japanese men undergoing transrectal ultrasound (TRUS)-guided systematic 8-core peripheral zone (PZ) biopsies. METHODS: Between October 2002 and December 2004, a total of 788 consecutive patients underwent TRUS-guided systematic biopsy of the prostate for the fi rst time. As a rule, 10 cores were taken from each patient; that is, 8 cores from the PZ, including the standard sextant cores and 2 cores from the anterior lateral horns, and 2 additional cores from the bilateral TZ. The cancer detection rate was calculated according to several parameters. We also assessed the disease extent on radical prostatectomy specimens according to the cancer location within the biopsy specimens. RESULTS: Prostate cancer was detected by 10-core biopsies in 209 (26.5%) of the 788 patients, and 11 of these patients had positive cores only in the TZ; that is, the increase in cancer detection rate by sampling two additional cores from the TZ was 5.3%. Among 209 patients diagnosed as having prostate cancer, radical prostatectomy without any neoadjuvant therapy was performed in 59 patients with positive biopsy cores in the PZ, 7 in the TZ and 32 in both the PZ and TZ. Patients with positive cores in both zones showed significantly less favorable characteristics, indicating more advanced disease than that in those with positive cores in either zone. CONCLUSIONS: Routine TZ biopsy did not significantly increase the detection rate of prostate cancer; however, the anatomical location of positive biopsy cores could provide additional information concerning disease extension in patients undergoing radical prostatectomy.     

超声引导前列腺12针系统穿刺活检术

目的　探讨经直肠超声引导下前列腺12针系统穿刺活检术诊断前列腺癌的临床价值。　方法　对220例行经直肠B超引导下前列腺12针(在传统6针基础上增加前列腺两侧外周带外侧底、中、尖部各1针)系统穿刺活检术的患者资料进行回顾性分析。　结果　前列腺癌患者73例(33. 2% ),临床分期T1 4例、T2 21例、T3 15例、T4 33例,如按传统6针穿刺方法穿刺,检出率为31. 4%,将有4例早期癌(T1 3例、T2 1例,体积均<0. 5ml)患者漏诊, 6针较12针穿刺漏诊早期癌16% (4 /25)。220例患者均未出现严重并发症。　结论　12针较6针系统穿刺活检可以增加早期癌和小体积癌( <0. 5ml)的检出,应重视对前列腺外周带外侧6点的穿刺。     

Examination for indication of systematic biopsy for diagnosis of prostate cancer]

BACKGROUND: Systematic biopsy has been commonly used for detection of prostate cancer. Nevertheless, as this examination occasionally gives patients severe complications it is necessary to give careful consideration for application of this examination. Thus, we analyzed retrospectively 145 cases who underwent transrectal ultrasonography (TRUS) guided systematic biopsy to evaluate the application of systematic biopsy, correlating with the findings of digital rectal examination (DRE), prostate specific antigen (PSA), the findings of transrectal ultrasonography (TRUS) and the results of biopsies. METHODS: Between May, 1995 and May, 1997, 143 patients who were suspected to have prostate cancer with either of PSA and DRE, and 2 patients who received visual laser ablation of prostate (VLAP), underwent TRUS guided systematic biopsy of prostate. We evaluated diagnostic efficacy of PSA, DRE, TRUS, prostate-volume-specific PSA, and PSA density (PSAD). RESULTS: Sensitivity, specificity and positive predictive value (P.P.V.) are 78.4%, 62.8% and 53.5% for DRE, 100.0%, 4.4% and 41.8% for PSA, 88.2%, 60.0% and 52.9% for TRUS, 87.8%, 72.1% and 64.2% for prostate-volume-specific PSA, 100.0%, 30.6% and 45.4% for PSAD, respectively. Ten of 69 patients (14.5%) whose PSA levels were 4.0 to 10.0 ng/ml were diagnosed as cancer, and positive for both or either of DRE and TRUS. Twenty-seven who were negative for both of DRE and TRUS were not diagnosed as prostate cancer. Using the combination of prostate-volume-specific PSA, DRE and TRUS, we could eliminate 29 non-cancer men (21.5%) whose PSA level was greater than 4.0 ng/ml from systematic biopsy. CONCLUSION: On the diagnosis of prostate cancer, the combination of prostate-volume-specific PSA, DRE and TRUS is very useful to exclude unnecessary systematic biopsy, if an urologist could be used to and trained for DRE and TRUS.     

Lateral biopsies added to the traditional sextant prostate biopsy pattern increases the detection rate of prostate cancer

Urologists routinely use the systematic sextant needle biopsy technique to detect prostate cancer. However, recent evidence suggests that this technique has a significant sampling error and data based upon whole-mounted step-sectioned radical prostatectomy specimens using a three-dimensional computer-assisted prostate biopsy simulator suggests that an increased detection rate is possible using laterally placed biopsies. The simulated 10-core biopsy pattern (traditional sextant biopsy cores and four laterally placed biopsies in the right and left apex and mid portion of the prostate gland) was shown to be superior to the traditional sextant biopsy. The objective of this pilot study was to confirm the higher prostate cancer detection rate obtained using the 10-core biopsy pattern in patients. We reviewed data on 35 consecutive patients with a pathologic diagnosis of prostate cancer biopsied by a single urologist using the 10-core biopsy pattern. The frequency of positive biopsy was determined for each core. Additionally, the sextant and 10-core prostate biopsy patterns were compared with respect to prostate cancer detection rate. Of the 35 patients diagnosed with prostate cancer, 54.3%(19/35) were diagnosed by the sextant biopsy only. The 10-core pattern resulted in an additional 45.7%(16/35) of patients being diagnosed solely with the laterally placed biopsies. The laterally placed biopsies had the highest frequency of positive biopsies when compared to the sextant cores. In conclusion, biopsy protocols that use laterally placed biopsies based upon a five region anatomical model are superior to the routinely used sextant prostate biopsy pattern. Prostate Cancer and Prostatic Diseases (2000) 3, 43-46     

Comparison of prostate biopsy schemes by computer simulation

OBJECTIVES: To compare the ability of different biopsy schemes to detect cancer and predict tumor volume using our previously described prostate biopsy simulation system. In addition, we used the simulation system to evaluate the optimal location of transition zone biopsies. METHODS: Digital reconstructions of 180 radical prostatectomy specimens were used. Forty simulations were performed on each prostate for 10 biopsy schemes, including a previously reported five-region peripheral zone biopsy pattern and a new 11-core multisite-directed scheme consisting of sextant, two transition zone, one midline, and two anterior horn biopsies. For simulation of the transition zone biopsies, paired near-midline biopsies were simulated, with needle insertion points from the apex to the base of the prostate and with needle advances of 1 to 4 cm before firing. A total of 1,180,800 individual biopsy tracks were simulated. RESULTS: The 11-core multisite-directed biopsy scheme had the highest detection rate for cancers greater than 0.5 cc. This scheme reliably detected cancer in 94% (138 of 147) of the cases. These results were significantly better than those of the sextant biopsy scheme (P <0.001) and the five-region 18-core peripheral zone scheme (P = 0.03). Compared with other schemes, there were increases in small-volume (0.5 cc or less) cancer detection by both the 11-core multisite-directed and five-region schemes, but they were not statistically significant. The multisite and the sextant plus four transition zone biopsy schemes had the best correlation of mean total core cancer length with total cancer volume. In the simulation of the transition zone biopsies, the highest detection rate was observed when the biopsies were initiated at the most apical section and inserted for a depth of 3 cm before firing. CONCLUSIONS: Our simulation results suggest that the detection rate of prostate biopsies is not related solely to the number of cores taken. Core placement (the regions of the prostate from which samples are taken) is also important. The 11-core multisite-directed biopsy scheme performed the best, with improved cancer detection rates and tumor volume correlation over other schemes. On the basis of our simulations, this scheme has been chosen for clinical evaluation.     

The potential impact of prostate volume in the planning of optimal number of cores in the systematic transperineal prostate biopsy

OBJECTIVES: We compared the detection rates of different transperineal prostate biopsy protocols with the aim to optimize the number of cores to sample according to prostate volume. MATERIAL AND METHODS: From October 2002 to October 2004 we evaluated 480 consecutive patients with PSA between 2.5 and 20 ng/ml undergoing the first set of prostate biopsy. All patients underwent a 14-core TRUS-guided transperineal prostate biopsy, including 12 cores in the peripheral and two in the transitional zone. The detection rate of the 14-core scheme was compared to the one of the other biopsy schemes obtained through the exclusion of pairs of cores. Data were stratified according to the different TRUS estimated prostate volumes. RESULTS: The detection rate of the standard sextant was 35.2%, while those of the 8-core schemes ranged from 37.1 to 38.8%. The 10-core schemes yielded detection rates of 39.6-40.8% and the protocol with 12 biopsies in the peripheral zone diagnosed prostate cancer in 42.1% of the patients. In patients with <30 cc prostate volume, the detection rate of the 14-core scheme was 43.8% and resulted statistically overlapping to the 8-peripheral cores protocol. In patients with 30.1-50 cc prostate volume a 12-peripheral core biopsy reproduced the results of the 14-core sampling. In prostates larger than 50 cc, an even more extensive procedure was mandatory, considering the low detection rate of the 14-core scheme (24.2%). CONCLUSION: Transperineal prostate biopsy is a safe procedure with a very low complication rate and high cancer detection rate. Prostate volume is the most relevant variable in the planning of the optimal number of cores in the extensive first biopsy set. A protocol with more than 8 peripheral cores) is recommended only in patients with prostate volume larger than 30 cc.     

The utility of apical anterior horn biopsies in prostate cancer detection

We sought to determine the utility of adding apical anterior horn biopsies to systematic prostate sampling regimens in detecting cancer in men with measured prostate volume < or =50 cc. We reviewed the biopsy data of consecutive men referred for an abnormal digital rectal exam or PSA elevation > or =4.0 ng/mL. All of these patients underwent lesion directed biopsy as well as a systematic 12-core biopsy regimen consisting of the standard sextant, bilateral lateral mid- and lateral base-sites, and bilateral apical anterior horn sites. Overall cancer detection and unique cancer detection rates were calculated for each of the 12 sites, stratified by race, age, PSA, and findings on digital rectal exam. In addition, cancer detection rates of various biopsy schemes were calculated and compared. There were 255 men undergoing biopsy who had calculated prostate volume < or =50 cc, and the prostate cancer detection rate was 47%. The overall cancer detection rate of apical anterior horn biopsies ranged between 29% and 56%. The utility of these biopsies was greatest in men with normal rectal exam and PSA <10 ng/mL, with unique cancer detection rates of 6% and 4%, respectively. Including the apical anterior horn biopsies in an 8-biopsy scheme (anterior, apex, lateral mid, lateral base) yielded cancer detection rates greater than 91% in all subgroups that were not statistically different from extended 10- and 12-core biopsy regimens. Apical anterior horn prostate biopsies target cancers that are potentially in the anterior region of the prostate, a region under-sampled using traditional schemes. The use of these biopsies as part of an 8-core biopsy pattern provides high cancer detection in all groups of patients and may represent a new standard.     

Transrectal ultrasound-guided transperineal 14-core systematic biopsy detects apico-anterior cancer foci of T1c prostate cancer

AIM: The optimal biopsy strategy for prostate cancer detection, especially in men with isolated prostate-specific antigen (PSA) elevation, remains to be defined. We evaluated diagnostic yield and safety of transrectal ultrasound (TRUS)-guided transperineal systematic 14-core biopsy and compared the spatial distribution of cancer foci detected with this technique in men with and without abnormality on digital rectal examination (DRE). METHODS: In a prospective study, 289 men aged between 50 and 87 years (median age, 70 years) underwent TRUS-guided transperineal systematic 14-core prostate biopsy because of elevated PSA and/or abnormal DRE findings. Using the fan technique, 12 cores from the peripheral zone and two cores from the transition zone were obtained systematically. To characterize the spatial distribution of cancer positive cores, site-specific overall and unique cancer detection rates were compared between stage T1c and T2 cancers. RESULTS: Prostate cancer was detected in 105 of the 289 patients (36%). Major complications requiring prolonged hospital stay or re-hospitalization during a 4-week postbiopsy period were rare (1.4%). Sixty-seven stage T1c cancers were identified. These cancers were associated with significantly lower PSA and a smaller number of cancer positive cores when compared with stage T2 cancers (n= 38). The overall cancer detection rate was highest at the anterior peripheral zone and the posterior peripheral zone in stage T1c and stage T2 cancers, respectively. The unique cancer detection rate at the anterior peripheral zone was significantly higher in stage T1c cancers than in stage T2 cancers. Therefore, when the prostate is extensively biopsied using the transperineal approach, cancer positive cores are characteristically distributed anteriorly in stage T1c cancers and posteriorly in stage T2 cancers. CONCLUSIONS: TRUS-guided transperineal systematic 14-core biopsy showed an apico-anterior distribution of cancer foci in stage T1c prostate cancers.     

Additional Midline Biopsies of the Peripheral Zone Associated with the First Endorectal Standard Sextant Pattern Improves the Accuracy of Prostate Cancer Detection in Japanese Patients

Objectives

This study was designed to estimate the improved accuracy of prostate cancer (PCa) detection resulting from additional midline biopsies of the peripheral zone in first standard biopsy.

Patients and Methods

Patients were classified into 3 groups: 402 cases of sextant biopsies (1995–2002), 488 cases of 8-core biopsies with 2 additional midline biopsies (2003–2006), and 391 cases of 10-core biopsies with 4 additional midline biopsies (2007–2012). The positive rate of each number of biopsies and changes in positive rates associated with prostate specific antigen (PSA) ranges were estimated.

Results

The positive rate of core biopsy significantly improved with increasing numbers of core biopsies (30.1% for sextant, 43.4% for 8-core biopsies, and 53.1% for 10-core biopsies). The accuracy of biopsies for each PSA range also significantly improved (22.3% for sextant, 30.0% for 8-core biopsies, and 43.2% for 10-core biopsies in the PSA gray zone [4.01–10 ng/ml]; and 26.5% for sextant, 52.9% for 8-core biopsies, and 71.8% for 10-core biopsies in the intermediate PSA range [10.1–20 ng/ml]). In the 208 cases with positive results using the 10-core biopsy method, the distribution of Gleason scores did not differ between the sextant only group and the midline site only group.

Conclusions

Additional midline biopsy was associated with improved accuracy of positive core biopsies in Japanese patients with a PSA range of 4.01–20 ng/ml.© 2015 S. Karger AG, BaselKey Words: Additional midline, Diagnosis accuracy, Prostate cancer, First endorectal biopsy, Systematic biopsy     

Value of Systematic Transition Zone Biopsy in the Detection of Prostate Cancer

Background:
We evaluated routine transition zone biopsies for the detection of prostate cancer.
Methods:
Systematic sextant transrectal biopsies, including 2 systematic transition zone biopsies (sextant biopsy group), were performed on 196 consecutive patients. Biopsies were based on indications from digital rectal examination and/or a serum PSA level greater than 4.0 ng/ml. During the same period, 21 patients with persistently elevated PSA levels and earlier negative systematic biopsies also had the sextant biopsy (re-biopsy group). The sextant biopsy group was compared with 1 24 cases in our previous cancer detection program who had systematic quadrant biopsies targeted to the peripheral zone (quadrant biopsy group).
Results:
Between the sextant and quadrant biopsy groups, the difference in rate of cancer detection was not significant statistically. Of the sextant biopsy group, 64 (33%) demonstrated malignancy, including 9 (4.6%) with cancer found exclusively in the peripheral zone and 55 (28%) both in the peripheral and transition zones. No cancer was found exclusively in the transition zone. Of the re-biopsy group, all 4 cancers (19%) were detected in the transition zone, 2 of them exclusively in the transition zone.
Conclusion:
Routine transition zone biopsies did not increase the detection rate of prostate cancer. Systematic transition zone biopsies proved useful to the patients with persistently elevated PSA values and negative results in previous systematic peripheral zone biopsies.     

Transperineal extended biopsy improves the clinically significant prostate cancer detection rate: A comparative study of 6 and 12 biopsy cores

BACKGROUND: We evaluated the improvement in the rate of prostate cancer detection when using a 12-core transperineal biopsy protocol including transitional zone biopsy. METHODS: Between April 2003 and November 2004, 247 consecutive men underwent transperineal systemic 12-core biopsy of the prostate. Six cores were obtained at the peripheral zone, four at the transitional zone and two at the apex. We examined the cancer detection rate in each of the 12 cores, and also determined the improvement of cancer detection resulting from the extensive 12-core versus standard 6-core biopsy. RESULTS: Using the extensive 12-core biopsy, prostate cancer was detected in 98 cases (39.7%). Prostate-specific antigen (PSA), PSA density, the positive rate in digital rectal examination and transrectal ultrasound findings were significantly higher in the prostate cancer group than in the non-prostate cancer group, and prostate volume was larger in non-prostate cancer group. Every site showed almost the same positive rate, between 17.8 and 21.5%. There were 20 cases which were positive in the extended biopsy, but negative in the sextant. The detection improved significantly (20.4%). The improvement of cancer detection in extended biopsy was better in men with PSA levels of 10 ng/mL or less (28.9%), PSA density 0.3 or less (25.8%), negative digital rectal examination (23.3%), and negative transrectal ultrasound (21.6%). Of these twenty patients, no cases with insignificant tumor were detected in the six prostatectomy cases. In particular, three cases of the six were transitional-zone-only cancer. CONCLUSION: Transperineal extended 12-core biopsy including 4 transitional zone cores is a more useful procedure than transperineal 6-core biopsy. Routine transitional zone biopsy, that is different from transrectal biopsy, might be useful for detecting biologically significant cancer.     

Value of prostate volume measurement using transabdominal ultrasonography for the improvement of prostate-specific antigen-based cancer detection

PURPOSE: To examine value of prostate-speci fi c antigen (PSA) adjusted by prostate volume measured using transabdominal ultrasonography in prostate cancer detection among men with elevated PSA. METHODS: 238 men aged 79 years or younger with serum PSA levels of 2.0-20.0 ng/mL and normal digital rectal examination fi ndings were studied in terms of total and free PSA, prostate volumes with transrectal (TRUS) and transabdominal (TAUS) ultrasonography and transition zone volumes with TRUS prior to transrectal 10-core biopsy. In addition to sole PSA values and the free-to-total PSA ratio, volume-adjusted PSA values, PSA densities determined by TRUS (PSAD(TRUS)), and TAUS (PSAD(TAUS)), and PSA transition zone densities (PSATzD) were compared using receiver operating characteristic (ROC) analysis. RESULTS: Prostate cancer was diagnosed in 58 (24.4%) of the 238 men who underwent prostate biopsies. Of the areas under ROC curves (AUC) of studied parameters, PSATzD (AUC 0.751) was the best and signi fi cantly superior to PSAD(TAUS) (AUC 0.664, P = 0.007). However, PSAD(TAUS) exceeded PSA (AUC 0.559, P = 0.004) and showed potential capability of a one-fourth reduction in unnecessary biopsies without spoiling sensitivity (90%). Cancer detection rate was only 4.2% in the 48 patients whose prostate volume in TAUS was > 50 mL and PSAD(TAUS) was < 0.075. CONCLUSIONS: Since PSAD(TRUS) and PSATzD were signi fi cantly superior to PSAD(TAUS), TRUS is feasible as the standard fashion to determine prostate volume in the diagnosis of prostate cancers. However, TAUS is also worthwhile as it can improve the prostate cancer detection using sole PSA, and primary use of TAUS has the potential to reduce the substantial number of unnecessary biopsy safely.     

Extensive biopsy using a combined transperineal and transrectal approach to improve prostate cancer detection

PURPOSE: Previous studies have indicated that 6-core transrectal prostate biopsy misses a considerable number of cancers. We performed an extensive biopsy protocol of 12-core sampling using both transperineal and transrectal approaches to determine the impact on the cancer detection rate. MATERIALS AND METHODS: We prospectively evaluated 402 men who underwent 6-core transperineal and 6-core transrectal biopsies simultaneously due to abnormal digital rectal examination (DRE) and/or elevated prostate-specific antigen (PSA) levels of 4.0 ng/mL or greater. Using the transperineal approach we obtained four cores from the bilateral peripheral zone targeting the lateral and parasagittal areas and two cores from the bilateral transition zone. The following transrectal biopsy was performed traditionally. We compared cancer detection rate between the extended 12-core procedure and conventional 6-core transperineal and transrectal groups in terms of total PSA and DRE findings. RESULTS: Using the extensive combined method, prostate cancer was detected in 195 cases (48.5%) and the detection rate significantly increased 7.2% and 8.5% compared to the transperineal and transrectal groups, respectively. According to PSA levels and DRE findings, the cancer detection rate by the combined method was significantly improved in patients with PSA levels of 4-10 ng/mL and negative DRE: 10.3% and 11.6% compared to the transperineal and transrectal groups, respectively. CONCLUSIONS: The extensive 12-core method significantly improved the overall cancer detection rate and was especially efficient for men with PSA levels of 4-10 ng/mL accompanied by a negative DRE finding.     

Prediction of clinically significant prostate cancer after negative prostate biopsy: The current value of microscopic findings

ObjectiveTo assess the current ability of atypical small acinar proliferation (ASAP), multifocal high-grade prostatic intraepithelial neoplasia (mHGPIN), HGPIN with atypia (PINATYP) and other non-malignant lesions to predict clinically significant prostate cancer (csPCa) in repeat prostate biopsies.MethodsThis retrospective study analyzed 377 repeat prostate biopsies, carried out between 2.014 and 2.017, and excluding those with previous PCa or 5-alpha reductase inhibitors treatment. ASAP, mHGPIN, PINATYP, prostatic atrophy, prostatic hyperplastic atrophy, proliferative inflammatory atrophy (PIA), chronic prostatitis, acute prostatitis, or granulomatous prostatitis, were prospectively reported after 12-core transrectal ultrasound (TRUS) systematic negative previous biopsies. 3T-multiparametric magnetic resonance imaging (mpMRI) was performed previous repeat biopsies. At least 2-core TRUS targeted biopsies of Prostate Imaging-Reporting and Data Systemv2 lesions ≥3, and/or 12-core TRUS systematic biopsy were performed in repeat prostate biopsies. The main outcome measurements were csPCa detection, which was defined when the International Society of Uro-Pathology group grade >1 and avoided biopsies. After logistic regression analysis the most efficient model was selected, nomogram was designed with internal validation, and clinical utility was analyzed.ResultsNormal benign tissue alone was present in less than 2% of previous negative biopsies. mHGPIN (39.7%), ASAP (4.3%) and PINATYP (3.7%) failed to predict csPCa risk in repeat biopsies. The finding of PIA (38.2%) associated with a decreased the risk of csPCa with an Odd ratio of 0.54 (95% confidence interval: 0.31–0.95), P= 0.031. The area under the curve, to predict csPCa, of mpMRI was 0.736, increasing up to 0.860 (95% confidence internal:0.82–0.90) when PSA density, age, digital rectal examination, and differential PSA between biopsies and PIA finding were integrated in a predictive model. At 6% threshold, more than 20% of repeat prostate biopsies were saved without missing csPCa.ConclusionCurrently, mHGPIN in negative prostate biopsy seems not able to predict the risk of future csPCa. The low incidence of ASAP and PINATYP, in our series, did not allow us to draw conclusions. PIA finding associated with a reduced risk of csPCa, and it could be integrated in a useful based-mpMRI predictive nomogram.     

Saturation technique does not improve cancer detection as an initial prostate biopsy strategy

PURPOSE: We reported on the results of a sequential cohort study comparing office based saturation prostate biopsy to traditional 10-core sampling as an initial biopsy. MATERIALS AND METHODS: Based on improved cancer detection of office based saturation prostate biopsy repeat biopsy, we adopted the technique as an initial biopsy strategy to improve cancer detection. Two surgeons performed 24-core saturation prostate biopsies in 139 patients undergoing initial biopsy under periprostatic local anesthesia. Indication for biopsy was an increased PSA of 2.5 ng/dl or greater in all patients. Results were compared to those of 87 patients who had previously undergone 10-core initial biopsies. RESULTS: Cancer was detected in 62 of 139 patients (44.6%) who underwent saturation biopsy and in 45 of 87 patients (51.7%) who underwent 10-core biopsy (p >0.9). Breakdown by PSA level failed to show benefit to the saturation technique for any degree PSA increase. Men with PSA 2.5 to 9.9 ng/dl were found to have cancer in 53 of 122 (43.4%) saturation biopsies and 26 of 58 (44.8%) 10-core biopsies. Complications included 3 cases of prostatitis in each group. Rectal bleeding was troublesome enough to require evaluation only in 3 men in the saturation group and 1 in the 10-core group. CONCLUSIONS: Although saturation prostate biopsy improves cancer detection in men with suspicion of cancer following a negative biopsy, it does not appear to offer benefit as an initial biopsy technique. These findings suggest that further efforts at extended biopsy strategies beyond 10 to 12 cores are not appropriate as an initial biopsy strategy.